This inspection took place on 6 December 2018 and was unannounced.

At our previous inspection of Garden House on 25 April 2018 we found several breaches of the regulations and as a result rated the service ‘Inadequate’ in Well Led and ‘Requires improvement’ overall. The provider was issued with a warning notice in relation to poor governance. You can read the report from our last inspection, by selecting the 'all reports' link for Garden House - Care Home Learning Disabilities on our website at www.cqc.org.uk.

At this inspection, we found the provider had made some improvements to the way the service operated. However, we found concerns in relation to some aspects of medicines management and quality monitoring. We rated the service 'requires improvement' overall.

Garden House is a 10-bedded care home for people with learning disabilities located in the London Borough of Southwark. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection there were eight people living at the service.

The service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. “People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy

A newly appointed manager had applied to become the registered manager of the service. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

Staff were employed following an application and interview process. The provider had made efforts to update and review DBS checks for all staff members following a recommendation we made at our last inspection.

People's needs were assessed before they moved into the service and further assessments were conducted once people were living in the home and feeling settled. This information was used to develop individual support plans. People and their relatives were involved in decisions about how care and support was provided.

Staff completed a range of risk assessments in relation to skin integrity, mobility, nutrition and continence. Most risk assessments had recently been reviewed and the quality manager told us that the remaining records would be completed shortly.

Staff were not always following safe practice regarding the management of people's prescribed medicines. Staff competency in relation to safe medicines practice was not being regularly assessed.

Staff completed an induction and were required to attend training and supervision sessions throughout their employment. Sufficient numbers of staff were deployed to the service to meet people's.

Staff understood how to recognise and respond to safeguarding concerns to keep people safe and told us they would report any concerns they may have to their manager.

Staff made appropriate referrals to health and social care professionals when needed. However, staff were not always following recommendations and guidance provided by clinicians.

People had enough to eat and drink but food supplies did not always meet people’s preferences.

The provider had policies and procedures in place that ensured staff had guidance if they needed to apply for a Deprivation of Liberty Safeguards (DoLS) authorisation to restrict a person's liberty in their best interests.

Staff treated people with respect and were mindful of people's need for privacy.

Relatives we spoke with provided positive feedback as to the way care

This inspection took place on 25 April 2018 and was unannounced.

Garden House is a 10 bedded care home for people with learning disabilities located in the London Borough of Southwark. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection there were nine people living at the service.

The service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy

The service did not have a registered manager. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’ An interim manager was responsible for the day to day running of this service and two other services operated by the same provider.

At our previous inspection of Garden House on 28 January and 1 February 2016 we rated the service ‘good’ overall. You can read the report from our last inspection, by selecting the 'all reports' link for Garden House - Care Home Learning Disabilities on our website at www.cqc.org.uk.

At this inspection we found several breaches of the regulations and as a result rated the service ‘inadequate’ in Well Led and ‘requires improvement’ overall.

People's individual needs were not always being met by the adaptation of the premises.

Risks in relation to people’s safety were not always being addressed through the implementation of a robust risk assessment process. Risk assessments were not always being reviewed in line with the provider’s policies and procedures.

Where appropriate, people, relatives and healthcare professionals contributed to the care planning process. However, care plans were not being regularly reviewed to reflect people’s changing needs.

Staff were not always receiving appropriate support and training to enable them to carry out the duties they were employed to perform.

People using the service were not always being protected from improper treatment. Staff were not always requesting people’s consent before offering them support.

People were not always being treated with dignity and respect. Some staff members lacked the understanding required to support people in a kind and compassionate manner.

The provider had safeguarding policies and procedures in place. Staff cited physical and verbal aggression as forms of abuse. However, staff were unfamiliar with the concept of institutional abuse. Where we identified concerns in this area, staff demonstrated a lack of understanding and awareness.

Not everyone using the service knew how to make a complaint.

Staff were employed following a thorough recruitment process. However, some DBS checks dated back to 2003 and had not been renewed since.

Staff were not always supervised on a regular basis and annual appraisals were behind schedule. Training was not always effective, updated or refreshed to ensure people were receiving care and support in line with evidence-based best practice guidelines.

Audits were carried out to ensure the environment and people were safe. However, systems designed to regularly assess, monitor and improve the quality of the service were not always effective.

People were supported to have sufficient amounts of nutritious food and drink to meet their needs. Mealtimes were not always organised in a way that promoted people’s choices and preferences.

Sufficient numbers of staff were

This inspection took place on 28 January and 1 February 2016 and was unannounced.

Garden House is a residential home that provides accommodation and support to up to ten people with learning disabilities in the London Borough of Southwark. At the time of the inspection there were 10 people living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People received their medicines safely and in line with their prescriptions. The service demonstrated good practice with regards to the administration, recording, auditing, storage and disposal of medicines.

People’s care plans were person centred and tailored to meet their needs. Care plans were regularly reviewed to reflect people’s changing needs. People were encouraged to develop and contribute to their care plans wherever possible.

People were protected against the risk of harm and abuse. Staff were aware of the correct procedure in reporting abuse and understood their responsibilities with reporting and recognising abuse and safeguarding. Staff were able to identify the different types of abuse and their responsibilities in maintaining people’s safety. People were protected against identified risks. Comprehensive risk assessments gave staff clear guidance on how to support people when faced with known risk.

People did not have their liberty restricted unlawfully. Staff had sound knowledge of the Mental Capacity Act 2005 [MCA] and Deprivation of Liberty Safeguards [DoLS]. These aim to make sure that people in care homes, hospitals, and supported living services, are looked after in a way that does not deprive them of their liberty and ensures that people are supported to make decisions relating to the care they receive. Consent to care was sought prior to care being delivered.

The service had carried out the necessary checks on new employees to ensure they were suitable to work in the service. Staff underwent a comprehensive induction programme to ensure they gained the appropriate skills and knowledge to effectively meet people’s needs. Inductions were flexible and could be extended if staff required additional time and support to be deemed competent.

People were supported by staff that received on-going comprehensive training that gave them the skills and knowledge to meet people’s needs. Staff received ongoing guidance and support through supervisions and annual appraisals. There were sufficient numbers of staff on duty to meet people’s needs.

People were supported to have sufficient amounts of nutritious food and drink to meet their needs. Food and drinks were available to people throughout the day as and when they chose.

People received access to health care professionals to monitor and maintain their health care needs. Staff supported people to attend health care appointments in the local community.

People were treated with dignity and respect at all times. Staff supported people in a kind and compassionate manner whilst maintaining their confidentiality.

People were supported to raise their concerns and complaints. The service had pictorial posters available in the service where people could access details on how to raise a complaint. People were encouraged to share their views and these were listened to.

The registered manager operated an open door policy and was a visible presence within the service. The registered manager actively sought partnership working health and social care professionals and sought feedback on the delivery of care. Quality assurance questionnaires were sent to people, relatives and health care professionals to seek their feedback and suggest improvements to the service.

The registere

This inspection was carried out to follow up on concerns identified at our last inspection on 4 September 2014 where we found the service to be in breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 relating to the management of medicines. The provider sent us an improvement plan on how they will meet this area.

We answered the questions: Is the service safe?

We checked the medicine administration record (MAR) for 10 people living at the service, observed the administration of medicines and we spoke to staff.

Is the service safe?

The home was safe. Medicines were administered and handled safely. MAR were accurately completed. People medicines were stored securely. Unused medicines were returned and a record was kept for these.

This inspection was carried out by an inspector who helped answer our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they felt safe living at the service. Staffing levels were adequate and staff were trained and competent in their roles. Staff were aware of how to respond to emergencies and there was support available for people 24 hours a day.

Assessments were undertaken to identify any risks to people that used the service and actions were taken to address the identified risk. Health and safety requirements were maintained. Staff had knowledge of the signs of abuse and how to report it.

Medicines were not always handled safely or appropriately. Unused medicines were not disposed of appropriately.

Is the service effective?

People were involved in the assessment of their care needs and in developing their support plans. Their support plans were tailored to reflect their individual needs and the outcomes they wanted to achieve. Other health and social care professionals were involved where required.

Is the service caring?

People were supported by attentive staff. Staff were patient, encouraging and caring. They spoke to people with respect. We saw positive interactions taking place. Most of the people told us that staff were nice and listened to them. People commented that they liked living at Garden House Care Home and that they liked the staff. We saw that staff spent time with people and engaged them in activities.

Is the service responsive?

People were able to take part in a range of activities in and outside the service regularly. Staff understood the individual needs of the people who used the service and supported them accordingly. Care plans and risk assessments were reviewed monthly to reflect changes in people’s needs.

Is the service well-led?

There was a range of quality assurance systems in place by the provider. The provider requested feedback from people who used the service about the quality of the service using surveys and monitoring visits. People knew how to make complaint.

Staff told us they were clear about their roles and responsibilities. Staff had regular supervision sessions, appraisals and team meetings to ensure they were adequately supported to do their jobs.

Garden House provided care and support for ten people at the time of our inspection. They had learning disabilities and required varying levels of assistance to express their views about the quality of the service. We found that people had busy activity schedules and they participated in many different social activities in the community. People we spoke with were happy with the staff and the service. They said that the home “is a nice place”, “Everything is ok” and that they go out to play bowling, to swim and to have a meal or drink in the pub. People said that they wouldn’t want to change anything.

Staff we spoke with were happy to work for the service and told us that they “Would recommend to others to work here”, “I’m happy here” and that “We are a good team”. We saw evidence that the provider operated an effective recruitment process to ensure that only suitably qualified, skilled and experienced people were employed at the service.

We observed during our inspection that people were treated with respect as individuals. People had care plans which included details of how to meet their nutritional needs and they were provided with a choice of suitable and nutritious food and drink.

We found that the home was clean and hygienic and that procedures were in place to prevent the spread of any potential infections. We also found that there was a system in place to respond appropriately if people had any complaints.

We spoke with three of the ten people using the service and three support workers. Two people showed us their care and support plans, and we looked at the records of three members of staff.

People we spoke with said they talked about what they wanted to do with their support workers. We observed they were involved in making decisions about their daily lives. The provider followed appropriate procedures when an assessment was required of people’s capacity to consent in relation to a specific decision.

People told us they liked living at Garden House, and one of them said “they’re like family”. People were encouraged to develop daily living skills and someone who had been living at the home for a few months said “I’m coming to be more independent”. They had access to health services, depending on their needs. Each person had an individualised programme of activities.

There were appropriate arrangements for the management of medicines and there were checking processes to make sure the administration of medicines was safe.

The people we spoke with said they liked the staff who worked at the home. One of them said “I have nice chats with the staff”. Support workers had access to a range of training courses and were well supported by their managers.

The records we reviewed were well ordered and up to date, and were stored appropriately.

"I like living here at Garden House, and cannot imagine living anywhere else",

"It is a great place to live, the people and staff are nice, I am busy and go out most days" were some of the comments received from people living in the home.

We observed the warm interaction between people in the home and the management and staff.

The consistency and stability of the staff team has enabled individuals achieve their goals and aspirations.

Staff were observed to understand fully the communication methods and tools used by individuals,